岩谷・出原・金森／日本保健医療行動科学会雑誌

38

32（2），2017

38－52〈Original Contribution〉 ���������������������������������

First-time Mothers’ Experience of Childcare Difficulties
as Perceived by Visiting Nurses and Nurses’ Support
for the Mothers:
as Focus on Visiting Nurses’ Narratives
Kumiko Iwatani ＊ Miwa Izuhara ＊＊ Kyoko Kanamori ＊＊＊＊The University of Shiga Prefecture＊＊＊＊＊

Aichi Medical University

Kyoto Koka Women’s University

訪問看護者が感じる初産婦の育てにくさとそれに関する対応：
訪問看護者の語りに着目して岩谷久美子＊ 出原弥和＊＊ 金森京子＊＊＊＊

滋賀県立大学＊＊

愛知医科大学＊＊＊京都光華女子大学〈Abstract〉
The objective of this study is to formulate recommendations for improving parenting support aimed at
resolving childcare difficulties experienced by first-time mothers by interpreting the responses of visiting
nurses who observed the parenting lives of such mothers during the postpartum period. Semi-structured
interviews with 14 postpartum visiting nurses were conducted, and the collected data were analyzed
using the Reissman’s narrative research approach. We identified seven themes related to the support that
visiting nurses provide to first-time mothers who are experiencing childcare difficulties. These themes
included support for women’s, such as offering advice regarding specific childcare acts and approach tosupport systems and psychological aspects. First-time mothers particularly need reconstruction of a followup system to monitor their self-management of breast milk. This study also recommends the need to clarify
the nature of support for mothers who experience childcare difficulties.
〈要旨〉
本研究の目的は , 産後訪問看護者が , 母親の初めての育児生活を観察し , 母親の育てにくさを感じた体験に対する対応を解釈し , 子育て支援の示唆を得ることである。産後訪問看護者 14 名を対象に , 半構造化面接を行い , Riessman のナラティブ研究法に基づいて分析した。その結果，訪問看護者が感じる初産婦の育てにくさの対応は，7 つのテーマが導き出され，心理面への働きかけ，具体的な育児行為のアドバイス，サポート体制への働きかけという特徴があった。特に初産婦には母乳の自己管理のためのフォロー体制の再構築が必要である。さらに育てにくさを感じている母親をとりまく支援の実態を解明する必要性が示唆された。

キーワード
childcare difficulties
experience
first-time mothernarrative
visiting nurse

育てにくさ
体験
初産婦
ナラティブ
訪問看護者

岩谷・出原・金森／日本保健医療行動科学会雑誌

Ⅰ．Introduction

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Therefore, healthcare professionals must carefully

As part of their nationwide crusade “Healthy

observe and intervene to avoid overlooking

Parents and Children 21,” Ministry of Health,mothers’ childcare difficulties. However, theLabor and Welfare of Japan aims to promotesupport which visiting nurses involved with

development of a peaceful mind of children

postpartum mothers provide to those who feeland decrease childcare anxiety. The measuresdifficulties in childcare after childbirth remains

reviewed the previous perspective of early

unclear.

discovery/treatment of the illness and healthguidance to that of childcare support, and public

Ⅲ．Study aim

health care centers developed care systems

The aim of this study is to formulate

covering the perinatal period and time after

suggestions to improve parenting support bydischarge, strengthening the development ofinterpreting responses of visiting nurses working

voluntary childcare support groups. Furthermore,with mothers and children in the community

cooperation is also being strengthened in hospital

toward mothers experiencing childcare difficulties

obstetrics departments in areas by identifying

during 1–4 months postpartum.

parents with low awareness about childcare
and parents with strong childcare anxiety, andⅣ．Methods

introducing them to community health agencies

１．Design

1)

or pediatric departments . Reportedly, childcare

The Riessman’s narrative research approach6)

anxiety is associated with child abuse, andwas used in this study. Talking enables a person

consultations regarding child abuse at childto continuously build new experiential andguidance centers nationwide have increased fromsubjective meanings7) and can dynamically reveal

17,725 cases in 2000 to 88,931 cases in 20142). Childthe meanings built by a narrator8).

abuse, therefore, remains an important challenge

２．Operational Definition

to be addressed in society as a whole.

Childcare difficulties can cause mothers
to feel inadequate in their maternal role by

Ⅱ．Literature review

inciting feelings of concern over childcare

Raising children involves much of both joy

and bewilderment over unfamiliar and stiflingand anger and childrearing is thought to be an

childcare, which may suggest developmental

emotional experience. The emotional experiences

disorders9). At times, some parents are not awareof parents are considered to have a major impactof their own childcare difficulties. The experiences3)

on childrearing . Notably, mothers of children who

are described as a direct contact with the external

show no illnesses during postpartum home visits

or internal reality, which include personal andcan occasionally provide smooth and enjoyablesocial practices of public health nurses andparenting and at other times feel stressed andmidwives.

struggling with care. Child abuse includes cases

３．Participants

where parents are feeling anxious over their

The participants were recruited from publicchild’s development and struggling to raise theirhealth centers mainly in the Kansai region of

4)child . The characteristics of childcare difficulties

Japan from among visiting nurses involved in theare also known to influence a mother’s attitude

work of visiting the homes of all infants. Some

toward childcare, causing childcare anxiety 5) .

participants were referred by other participants.

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岩谷・出原・金森／日本保健医療行動科学会雑誌

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The visiting nurses enrolled in this study were

subjective experiences. Interview contents

those engaged in home-visit activities andwere first transcribed, and data regarding

provided informed consent before participation.

observations made during the interviews were

The study was conducted from September 5, 2013,

added. Transcripts were then read carefully toto March 31, 2014. Postpartum visits are usuallyascertain the overall description of the narrative.

provided by public health nurses and midwives

Thereafter, sequences and plots were identified inthroughout the country, and information content

the transcripts in which the childcare difficulties

for childcare support has been standardized toof first-time mothers and the support weresome extent with their national qualification;

recounted, and a story was gleaned to understandtherefore, public health nurses and midwives wereand interpret the expressions of accompanying

selected as the study participants.

emotions, the relationship between these

４．Data Collection

expressions, and the relationship with the overall

Visiting nurses were asked to freely andnarrative. Since a story emerges and the meaning

naturally talk about their work with mothersof the story is constructed through an interaction

who faced childcare difficulties. Interview

between a narrator and a listener, we believed

venues were specified by participants, and thethat a narrative method would be appropriate forinterviews were conducted on a one-on-one basis.

this study to explore and interpret the nurses’

The interviewers had no personal acquaintance

responses in an effort to develop support forwith the participants. At the beginning of themothers with childcare difficulties. We divided

interview, it was confirmed that cases experienced

the visiting nurses narratives into six structuresby participants were of first-time births for the(abstract, orientation, complicating action,mothers and that both mothers and infants didevaluation, resolution, coda) that Labov mentioned

not require a medical follow-up. Participants wereby Riessman (2008) and analyzed.

asked to state in their stories whether the mothers

６．Rigorwere not aware of childcare difficulties but the

Narrative analysis is a process of interpreting

nurses realized their difficulties to some extent.

similarities and differences in the stories of

The interviewers checked their interpretations

different study participants and identifying

against the information provided during therecurrent themes6). To guarantee the exactness ofinterviews or asked some questions to get morethis qualitative research, a qualitative researcher

details. The content of interviews was recorded onsupervised the entire process of data collection,an recorder with the permission of participants.

analysis, and interpretation.

However, if participants refused to be recorded,

７．Ethical Considerations

a permission was obtained to take written notes.

This study was approved by the Institutional

Prior to the interview, a pre-interview was

Review Board of Kanazawa Medical University

conducted with the collaborating researchers(Kanazawa City, Japan; approval no.: 180). Before(interviewers) to discuss methods of interview.

the study, the directors of the participating

５．Data Analysis

facilities and study participants were given

The elements of theme analyses, structure,

written and verbal explanations of the overview

and dialog analyses were employed, based on

and purpose of this study. Study participation

6)

the Riessman’s narrative research approach , towas voluntary and all participants provided

analyze the spoken content of visiting nurses’

their informed consent after being assured that

岩谷・出原・金森／日本保健医療行動科学会雑誌

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they were free to decline or withdraw from thestructure (other than abstract) in stories narrated

study at any time and without any associatedby visiting nurses.

disadvantages. In addition, participants’ privacy
was ensured by conducting interviews in a private

Theme 1: Helping to organize thoughtsroom so as to avoid making the participatingby showing attitude to listen to

facility and participants personally identifiable.

grievances and trust gained by time
Visiting nurses observed that mothers had a

Ⅴ．RESULTS

sense of loneliness and isolation, and a desire to

１．Participants’ Characteristics

have someone listen and talk to.

The attributes of participants in this study

Nurse ID1 visited a recent new mother whose

are presented in Table 1. Mean participant age

husband was busy and had no contact with her

was 45.8 years and mean years of experience inchild. The woman could not bear with the marital

postpartum home visits was 8.3 years.

quarrels and was constantly frustrated. The nurse

２．Themes

gained her trust by listening to her story carefully

Notably, seven themes emerged fromand gave advice regarding participating in local

interpretations of experiences. Specific shortparenting groups. During the visits, the nurse also

stories (abstract as a structure of narrative

witnessed fights between the couple. By listening

element) and interpretations of each theme areto the woman’s story upon each visit, the nurse

presented below. Areas corresponding to themes

relieved her stress, which seemed to provide her

are underlined. Table 2 shows a narrative element

satisfaction from having someone to listen and

Table 1

Participating profiles
Characteristic

Sex
Man
Woman
Age, years
20–29
30–39
40–49
50–59
60–69
Years of experience in postpartum visits, y
<1
2–5
6–10
>11
License (qualification)
Midwife and registered nurse
Public health nurse and registered nurse
Current work
Postpartum visits and other work
Years of nursing experience
Hospital work experience
Public health center work experience
Interview duration (min)n = 14
N (%) or mean ± standard deviation
0(0)14 (100)
1 (0.7)5 (35.7)
2 (14.3)
4 (28.6)
2 (14.3)
1 (0.7)6 (42.9)
4 (28.6)
3 (21.4)
9 (64.3)
5 (35.7)
14 (100)
14 (100)
8 (57.1)
49.6 ± 10.9

Orientation

She may find a song “Ilove my mom” relaxing.

When she listened to thesong, she suddenly started crying. I informed
her that she could bemuch more confident in
her ability to care forher child.

By sympathizing
with the mother’s
feelings, nurses canhelp the mother tobe relaxed.

2

1

Theme
No.

Praising parenting, conveying future
prospects, anddeveloping aclose relationship with mothers to remove
the strain of amaternal role

Helping to organize thoughts
by showing attitude to listen togrievances andtrust gained by
time

Theme

32（2），2017*Details of the summary, which is one of the structures of narrative elements, are presented in the short stories in the paper (results section).

ID11

The mother was concerned with
the infant not breastfeeding welland a possible congenital hip dislocation. I informed her that possibility of congenital hip dislocation
can be followed up during a healthcheck-up, and after observing her
breastfeeding, I let her know that
it was going well.

I could not help her
to total stabilize
her mental state,
but I felt that she
was glad to have ahome visit.

Although I explained to her repeatedly, the mother kept repeating
the same questions.
Ultimately, I asked
her intention, “whatwould you like todo?”Talking to somebody who actively
listens can help themother to organize
her own opinions
or thoughts.

Coda

岩谷・出原・金森／日本保健医療行動科学会雑誌

I visited a first-time
mother aged 37 years
at 2 months postpartum.

I believed that the moth- As I listened to her
er wanted my approval while maintaining thethat she was trying hard eye contact, her facial
to care for her infant and expression softened.
that she was not making She seemed to open
any mistake.
up her mind graduallyand started smiling. She
voluntarily talked about
indications of her child’s
growth.

When I had a teleThe mother had prepared many
phone conversationquestions. The mother stated, “Iwith the mother, I
am having a hard time because
had an impression
people around me seem to thinkthatthemotherwas
it is normal for mothers to go on
ID2
depressed. During the even with lack of sleep.” The mothhome visit, the moth- er seemed to be mentally stressed
out. I assured her that the infant is
er looked depressed
growing well and that she is doing
and appeared tired.
a good job.

ID4

Today’s parents have no I attentively listened.
sibling or a role model
Usually, home visit lasts
and feel nervous because for 1 hour, but I spent 3
the first child they have hours in listening to her.
to care for is their own
child. This leads to anxiety. Without an appropriate guidance, it could
lead to further anxiety
with childcare.

Resolution

The mother was visit- The mother asked the same quesed at 3 months post- tion many times. I wondered if mypartum, as she was in explanation was insufficient andher hometown until 2 repeatedly confirmed the responsemonths postpartum.
and the question.

Evaluation
Under such circumstanc- Being heard during
es the infant cannot beeach home visit seemed
nursed well. I need toto relieve the mother'slisten to the mother well stress. It also led to aand earn her trust. It is sense of satisfaction, andobvious that the mother her facial expressions
is frustrated.
improved.

actionThe mother and her husband
constantly fight, and the motherwas always frustrated. She seemed
restless during the home visit andappeared frustrated.

Complicating

Narrative element structure in narratives of visiting nurses

Visited a mother who
was in her mid-thirties, shortly afterID1 delivery. Her husband is busy and has
little contact with theinfant.

Visiting
nursesTable 2-1

42

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Since there was no problem with
The child is quiet when
the weight gain and the reason
being held by the mothfor such a behavior was unclear,er. Since there is no
I asked the mother to breastfeed
problem with breast
the child in front of me. The childmilk supply, I wonderedpushed the breast away. The
if an expert help would
mother said, “all I can give is breast be useful or at least
milk. This makes me feel like I am gives the mother peacebeing rejected.”of mind.

I had a midwife take alook but there still was
no problem with breastfeeding, and the motherwas advised to continue
with breastfeeding.

The mother continued breastfeedingwith the midwife’s
support but did not
try too hard.

If we explain how
to adapt from difficult and anxious
childcare to easy
and fun childcare,the mother can actually enjoy childcare.

It is effective torepeatedly explain
specific childcare
methods that suitthe infant’s characteristics.

Coda

4

3

Theme
No.

Encouraging
breast self-carewhile supporting breastfeeding and serving
as a go-between
with specialists
when needed

Proposingspecific enjoyable childcare
methods suited
to women’s
lifestyles

Theme32（2），2017*Details of the summary, which is one of the structures of narrative elements, are presented in the short stories in the paper (results section).

Because the mother was While we acknowlThe mother consulted The mother had pain in her breast The child appeared tobe satisfied with theunable to breastfeed,edge the mother’sme about breastfeed- and a slight fever. She had visited
she was diagnosed with willingness to coning. Both mother and a clinic the day before, and because one healthy breast. We
mastitis and was treated. tinue breastfeeding,child were doing well there was excessive discharge, she milked for 2 hours, but
was instructed to ice the affected
the affected breast was
support for breastat 1 month postpartum.
breast and not to breastfeed. Bestill tight and it appeared
feeding or milking
cause her nipple was short, she was to be a difficult case.
should be provided,
ID9
unable to milk on her own, unable
and if it is difficult
to touch, and the child could not
to determine thebe breastfed. Thus, I provided help
need for special
with milking.
support, referral
to a specialist at
an early stage isimportant.

ID7

The mother complained that the child
was not acceptingher.

The mother was very
anxious, which is understandable becauseof a long hospitalization
before delivery. I would
like the mother to be
more positive with her
initiatives.
When I explained childcare products and methods that are enjoyable,
the mother appeared tobe more engaged.

Resolution

The mother said that she wasunsure of childcare, and I answered
her questions one by one while
confirming her childcare skills.

Evaluation

I visited a mother,
who was hospitalized
at 30 weeks of gestation and was disID14 charged after birth at
1 month postpartum.

actionI supported the motherat her own pace andcooperated with the hospital and public healthcenter. I checked herparenting skills at thenext home visit.

Complicating

When the mother held the child,
I found that the moththe child’s head was lower thaner took a lot of time tothe body, and she complained, “the do anything related tochild does not settle.” I explained
childcare, and forgive if
how to hold the child and change
I am being rude, I founddiapers. The mother’s body temher to be uncoordinated.
perature was low. I advised her to However, I felt that she
have consumable food ready and on was trying the best she
how to improve her circulation.
can.

Orientation

Narrative element structure in narratives of visiting nurses(continued)

When I visited her,
she was wearing her
pajamas, her house
was a mess, and curID8 tains were closed.

Visiting
nursesTable 2-2

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If the growth of the
I observed the breast
milk supply and assessed child is not properthe infant’s breastfeeding ly determined, themother’s anxiety
as well as body weightto evaluate the growth. would increase.
I could predict that thischild would grow at his/her own pace.

Generally, theI informed the motherthat the child was grow- child’s continuous
crying can be a
ing well and that thecause of a mother’s
excessive crying wasstress.
likely to be the child’scharacteristic. Once she
knew that she was doing
well, she smiled.

We cannot evaluate theinfant’s condition based
solely on body weightgain.

Since the mother was concerned
The mother had a grimthat her infant kept crying, I adexpression, and she did
vised that if it is not hunger or
not appear to be enjoydirty diaper, she should try holding ing childcare.
and comforting the child or increase
the amount of milk.

The mother was a
full-time housewife
in her early thirties.
She had no plan togo back to work. She
ID13 moved to her hometown for a monthafter the birth, andthe home visit wasprovided at 2 months
postpartum.

6

5

Theme
No.

Advising mothers to respondto their child’s
crying andconveying theimportance of
discovering thechild’s personality

Assessing andexplaining thechild’s state ofdevelopment

Theme

岩谷・出原・金森／日本保健医療行動科学会雑誌
32（2），2017*Details of the summary, which is one of the structures of narrative elements, are presented in the short stories in the paper (results section).

Everyone feels anxWhen she listened tothe song, she suddenly
ious about caring
started crying. She was for their first child.
basically a well-organized By sympathizing
person and seemed towith the mother’sfind a mother's role diffi- feelings, nurses cancult. I informed her that help the mother toshe could be much more be relaxed.
confident in her ability
to care for her child.

The mother was concerned as others commented that her child was
not growing well based on small
increase in the body weight. However, although the infant’s bodyweight was low, it was increasing.

Coda

If the growth of the
I observed the breast
milk supply and assessed child is not properthe infant’s breastfeeding ly determined, themother’s anxiety
as well as body weightto evaluate the growth. would increase.
I could predict that thischild would grow at his/her own pace.

Resolution

I visited a mother of
infant whose bodyweight had not normalized even thoughbreastfeeding was
ID5 going well. Althoughamount of increasein the infant’s bodyweight was low, theinfant was in a good
mood.

ID10

She may find a song “Ilove my mom” relaxing.

We cannot evaluate theinfant's condition based
solely on body weightgain.

Evaluation

The mother was concerned with
the infant not breastfeeding welland a possible congenital hip dislocation. She seemed to become anxious when she was alone at home.
I informed her that possibility ofcongenital hip dislocation can befollowed up during a health checkup, and after observing her breastfeeding, I let her know that it wasgoing well.

actionI visited a first-time
mother aged 37 years
at 2 months postpartum.

Complicating

The mother was concerned as others commented that her child was
not growing well based on small
increase in the body weight. However, although the infant’s bodyweight was low, it was increasing.

Orientation

Narrative element structure in narratives of visiting nurses(continued)

I visited a mother of
infant whose bodyweight had not normalized even thoughbreastfeeding was
ID3 going well. Althoughamount of increasein the infant’s bodyweight was low, theinfant was in a goodmood.

Visiting
nursesTable 2-3

44

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Orientation

Complicating

actionEvaluation

Narrative element structure in narratives of visiting nurses(continued)

The mother was nervous and worried about various small things. She
often talked about her friends’ “experiences,” but these friends were
strangers online, and her questions
were not solved via the Internet.

Coda

I was quite surprised to I solved her questions
find out that her friends one by one.
were strangers online. I
felt that this was a completely different era fromwhen I was raising mychild(ren).

Mothers should be
able to distinguishbetween accurate
and inaccurate
information. We
continued to discuss her questions
over e-mail after
the home visit.

I continued giving her
To provide accuadvice on childcare via
rate informatione-mail. Six months later, on childcare andthe mother returned to an environment
her parents’ home as her that relieves thehusband was not cooper- mother’s stress,
ative with childcare.
intervention involving people aroundthe mother is also
necessary.

Resolution*Details of the summary, which is one of the structures of narrative elements, are presented in the short stories in the paper (results section).

ID12

I visited a mother in
her thirties. She wasan introverted andquiet mother.

A young couple (18The mother said, “I do not get
She looked depressed,
year old) married be- sufficient sleep because of childcare, and it made me worried.
cause of the pregnan- and I am having hard time as thiscy, and because they is totally different from my previous normal life.” She was frustrated
could not financially
ID6 manage on their own, that her husband complained of her
insufficient housekeeping. I acthey were living at
knowledged her effort in childcare
the husband’s parents’ house. The home and informed her that the breastvisit took place at 1.5 feeding was going well.
months postpartum.

Visiting
nursesTable 2-4

7

Theme
No.

Arrangement
an environment
where accurate
information canbe provided andadvice can besoughtTheme

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岩谷・出原・金森／日本保健医療行動科学会雑誌

help in organizing her own thoughts.

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38－52

Nurse ID11 visited a 37-year-old recent new

Nurse ID4 discussed the case of a 3-monthmother at 2 months postpartum. The woman was

postpartum visit to a recent new mother who had

worried that her child was not breastfed proper-

spent at her parent’s home for the first 2 months

ly and might have congenital hip dislocation. In

after the birth. Despite the nurse’s explanations,addition, she appeared prone to worrying about

the woman repeated the questions. The nurse

everything when left alone at home. The nurse

wondered whether this was because of inadequate

explained that congenital hip dislocation could be

explanations, and continued making remarks

followed up in a later health check-up, observed

admitting to this fact. The explanations provided

the breastfeed, and commended the woman forraised the woman’s childcare anxiety and she wasbreastfeeding well. When the nurse played theunable to make her own decisions without having

song “Okaasan Daisuki” (I love you mom) to relax

matters explained. Although the normal time for a

the woman, she suddenly burst into tears. The

visit is about 1 hour, the nurse spent up to 3 hours

nurse explained that it was okay to have confi-

listening to the woman’s stories.

dence in parenting.

The visiting nurse gained the woman’s trustThrough these interactions, visiting nurses de-by carefully listening to the woman’s story atveloped a close relationship with mothers by offer-

her own pace. In doing so, the nurse helped theing praise and approval regarding childcare, andwoman to gather her thoughts by letting her

provided support by talking about future pros-

speak out her doubts and discontentment.

pects to relieve the excessive burden associated

Theme 2: Praising parenting, conveying

with the maternal role.

future prospects, and developing a close

Theme 3: Proposing specific enjoyable

relationship with mothers to remove thechildcare methods suited to women’s

strain of a maternal role

lifestyles

Visiting nurses perceived that active aware-

Visiting nurses observed that mothers

ness of a maternal role created a perfect image

experienced childcare difficulties when theyof a mother, causing a burden on mothers, andexhibited grim facial expressions and did not

childcare difficulties without prospects further in-appear to enjoy parenting.

creased anxiety over childcare.

Nurse ID8 visited a 25-year-old mother at 2

Nurse ID2 sensed a grimness in the answers ofmonths postpartum. The woman complained ofa mother during a phone call to make an appoint-difficulty in breast milk generation. During thement for a visit. During the visit, the new mothernurse’s visit, the woman was in her pajamas, thelooked downwards and appeared tired. When thehouse messy with the curtains drawn. When thenurse rewarded the woman for her childcare prac-

mother held her child, her head was lower thantices since leaving the hospital, the woman burst

the child’s body and the woman explained, “theinto tears. She explained that people around herbaby won’t calm down.” The nurse explained how

believed that a new mother should do her best

to cradle the infant and how to change diapers.

despite sleep deprivation. She had undoubtedly

The woman’s husband was in charge of all thedesired approval from someone for doing her bestcooking and household chores, and the woman

and engaging childcare the right way. The nurse

did not eat if there were no meals prepared byprovided words of sympathy by explaining theher husband. Besides, the woman’s body was cold.

child’s development and future prospects.

The nurse took time to explain how to prepare岩谷・出原・金森／日本保健医療行動科学会雑誌

32（2），2017

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47

food that could be stored, and how to improveto drink only at the beginning of breastfeeding.

her sensitivity to cold in a manner suitable for the

The midwife speculated that this refusal could

woman’s relaxing pace. The nurse checked thebe an individual trait of the child and advised thewoman’s childcare skills during subsequent visits.

woman to be patient with breastfeeding.

Nurse ID14 made a 1-month postpartum visit

Nurse ID9 visited a 30-year-old new motherto a mother who had been discharged from theat 6 weeks postpartum. The woman was

hospital after being admitted and going into labor

applying cooling pads on her breasts because

at 30 weeks of pregnancy. Because the womanof hypersecretion of breast milk and was also

remarked that she did not understand how tosuffering from breast pain with a slight fever. She

provide childcare, the nurse explained to her step

had visited a clinic a day before and had beenby step. For example, the nurse explained how to

instructed to apply cooling pads on her breasts

check an infant’s growth for healthy development

because of hypersecretion and not to feed her

and how to bathe an infant because of the vernix

child on the breast. The woman’s nipples were

caseosa that remains in places even 1 month after

short and she could not pump breast milk by

the birth. The nurse also taught the woman someherself. The nurse, therefore, assisted the mothertips for childcare to provide some comfort because

pumping her breast milk. However, subsequently,

comfort makes tasks more enjoyable.

self-care management was not successfully per-Visiting nurses taught mothers the specifics ofchildcare skills and offered them support to bringformed, resulting in development of mastitis which
required medical treatment.

comfort to mothers and make childcare enjoyable

Nurses need to encourage the woman towhile also respecting the lifestyles of each couple.

perform breast self-care while acknowledging

Theme 4: Encouraging breast self-carethe woman’s desire to maintain breastfeeding

while supporting breastfeeding andher child. When breastfeeding is not successfully

serving as a go-between with specialists

performed, nurses should assist with breastfeedingwhen needed

and pumping breast milk. The nurse acted as a

Visiting nurses stated that poor breast self-carecaused childcare difficulties.
Nurse ID7 visited a 35-year-old mother at 2
months postpartum. As the woman mentioned

go-between with specialists when clinical decision
making was difficult.
Theme 5: Assessing and explaining thechild’s state of development

about her child’s refusal to feed, the nurse

Visiting nurses observed that children’s

observed a breastfeeding session. When thedevelopment was not clearly recognized bychild made a gesture of refusal of breastfeeding

mothers, and this uncertainty in child developmentwith his hand, the woman burst into tears. The

was associated with their childcare difficulties.

woman explained, “I can only give breast milk. It

Nurse ID3 visited a mother when her child was

is saddening that my child seems to refuse me.”breastfed well but had substandard weight gain.

Although the child drank baby formula from a

Although the child’s weight gain was low, thebottle without a problem, the reason for the child’schild was in good spirits. However, the woman

refusal of breast milk was unclear. The nurse,

was concerned about the shortage of her breast

therefore, asked a local midwife for a breast di-milk. Usually, a child’s development must be

agnosis. The midwife found no problem with theestimated not only from the child’s weight gain,

woman’s breasts and the child seemed to refuse

but also from the child’s feeding condition while岩谷・出原・金森／日本保健医療行動科学会雑誌

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observing a mother’s secretion of breast milk.

Nurse ID13 visited a mother who had stayed her

Apparently, each child develops differently; theparent’s home for about 1 month after childbirth.

nurse, therefore, monitored the child while predict-

The nurse visited at 2 months postpartum and theing the growth during subsequent visits. Despite

woman complained that her child would not stopa low amount of weight gain, the child’s weightcrying. The nurse advised the woman to check

gradually increased.

the needs for feeding or changing diaper, and if noNurse ID10 visited a 27-year-old mother onneeds for them, to try to hold or soothe the crying

request at 24 days postpartum. The woman’s

child, or to increase the volume of milk. However,Edinburgh Postnatal Depression Scale score was

the woman’s facial expressions were grim andslightly elevated and she was tired from the lackshe did not appear to be enjoying parenting.

of sleep because of frequent breastfeeding. Her

The nurse explained that the child was growing

child had a rate of weight gain of 52.3 g/day andhealthily; therefore, crying should be considered as

the child appeared to be fussy because of over-a characteristic of the child, and that the woman’s

feeding. The nurse explained the child’s state ofcurrent responses were appropriate.

development and offered continuous telephonic

Visiting nurses supported mothers inadvice, which assuaged the woman’s mental state.

responding to their child’s crying. In addition,

Visiting nurses conveyed to mothers thethe nurses advised that if nothing would stop theappropriateness of childcare to date and areas

crying, perceiving it as a characteristic of thefor improvement by assessing and explaining thechild was necessary when the child was showing

child’s state of development based on factors sucha healthy growth.

as weight gain, mood, and feeding status.

Theme 7: Arrangement an environment

Theme 6: Advising mothers to respondwhere accurate information can beto their child’s crying and conveying theprovided and advice can be sought

importance of discovering the child’s
personality
Visiting nurses perceived a child’s crying as a
stressor to mothers.

Visiting nurses perceived that the lack of a
supportive environment and people to consult
regarding simple parenting questions andproblems was associated with childcare difficulties.

Nurse ID5 visited a new mother at 1.5 months

Nurse ID6 visited a young couple, both 18 years

postpartum. Notably, the woman’s husband lived

old, who had married after the woman conceived.

separately for his work. The woman was seeking

The couple was living at her husband’s parents’advice on the appropriateness of her breasthome because of the financial difficulties of living

milk secretion volume and on responding to her

on the couple’s income alone. The woman’s bothchild’s crying. The woman’s breast milk secretion

parents-in-law worked and the nurse’s visit was

was preferable, the child was feeding well, andat 1 month and half postpartum. The woman

there was no problem observed at all. However,explained with a grim expression, “I am not

the nurse explained that the child’s crying aftergetting enough sleep even at night, because ofbreastfeeding was an individual trait and thechildcare. It’s tough because this is totally different

mother would need to be patient. The nurse

from my previous everyday life.” The woman had

visited every 2 weeks at the woman’s request andbeen reprimanded by her husband for failing to

explained that she could also be reached by an

perform household chores and felt dissatisfied.

e-mail or a phone.

The nurse acknowledged the woman’s efforts with

岩谷・出原・金森／日本保健医療行動科学会雑誌

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49

childcare and explained that breastfeeding was

visiting nurses provided support for psychologicalalso going well. The nurse subsequently gave ad-

aspects of mothers by assisting mothers tovice on childcare over an e-mail. Six months later,organize their thoughts, and explaining future

the woman returned to her own parents’ homeprospects, praising parenting, and removing thewith her child because of the lack of cooperation

strain of a maternal role. Nurses also proposedfrom her husband.

enjoyable childcare methods suited to women’s

Nurse ID12 visited a mother aged in her

lifestyles. A parent’s enjoyment of childcare isthirties. The woman had been communicatedenjoyment that can bring happiness to theirwith strangers on the Internet about childcare

child11). If a parent were to experience enjoyment

questions. However, she was feeling conflictedfrom childcare, the joy of bringing happiness toover the differences between information on thetheir child would also be increased.

Internet and reality. She was unable to determine

Meanwhile, the mothers who experienced

what information was correct and what waschildcare difficulties had many concerns regarding

incorrect. The woman had prepared many ques-breastfeeding 12). Generally, mothers who havetions for the nurse’s visit, in which the nurse re-a strong desire to breastfeed their child but

solved one by one and continued to provide advice

repeatedly encounter problems with breastfeeding

via e-mails.

are psychologically cornered 13). As a mother

Visiting nurses supported mothers by arranging

is required breastfeed her child at all hours ofan environment where support, follow-up, andthe day, the rhythm of her life is likely to beaccurate childcare information could be provided

disturbed; however, as breastfeeding routine is

at any time in accordance with modern society, inestablished, the mother becomes able to accept

which the Internet has been used more widely, forsuch a changed life’s rhythm. The visiting nurses

example.

in this study observed the mothers and their childduring breastfeeding and encouraged breast self-

Ⅵ．DISCUSSION

care while supporting breastfeeding and serving

In Japan, a lack of improvement has been

as a go-between with specialists when needed.

observed in the percentage of parents who

Furthermore, mothers also require support inexperience childcare difficulties, i.e., mothers who

giving up breastfeeding 14).

have no confidence in parenting or those who

Apparently, children’s crying and restlessness

1)

are unable to calmly spend time with their child .

have been cited as the causes of stress in

In particular, mothers who have given birth tomothers 1 month after childbirth, and mothers

their first child are likely to lack confidence inare consequently taught how to respond to

all aspects of childcare because everything isthese behaviors during their hospitalization

new to them and they have a lack of experience

after delivery 15)16). Mothers are more prone toin childcare and new life with their child. For

experience negative emotions when they believe

such mothers, it is difficult to relax and deal withmore strongly that they must respond skillfully

childcare10). By developing proactive awareness ofto their child’s crying 17) . This could also be

a maternal role, forming a perfect maternal image,connected to child abuse. Visiting nurses in thisand driving themselves to live up to this image,study, therefore, provided specific advice, suchmothers were experiencing childcare difficulties.

as assessing and explaining the child’s state of

The results of the present study showed thatdevelopment and responding to the child’s crying

岩谷・出原・金森／日本保健医療行動科学会雑誌

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specific enjoyable childcare methods suited toand discovering the child’s personality.
Parent and child tend to develop a one-on-

women’s lifestyles, (4) encouraging breast self-

one relationship after childbirth because of thecare while supporting breastfeeding and serving

isolation of the parent engaging in childcare.

as a go-between with specialists when needed,Thus, visiting nurses have developed a support(5) conveying the importance of responding

framework in which an environment is createdto a child’s crying and identifying the child’s

where accurate information can be provided andpersonality, and (6) assessing and explaining

advice can be sought anytime. In England, threea child’s state of development, i.e., offeringin four of paternity leaves have been received

advice regarding specific childcare acts; and (7)18)

by fathers . Admittedly, the development

providing accurate information and arranging

19)

an environment where advice can be sought,

and nurses in Japan need to encourage fathersi.e., having an appealing support system. Many

to become more actively involved in childcare.

childcare difficulties experienced by first-time

Social support from husbands and other family

mothers are associated with inadequate self-

members is a factor that influences the growth

management of breast milk, which linked toand development of children and the psychologicalanxiety over their child’s growth. In addition

process of fathers as a father is also important

20)21). Further studies are needed

to reconstructing a follow-up system to allow

to clarify the characteristics of approaches formothers who have returned to the community

the surrounding people who support mothers

to successfully self-manage their breast milk

experiencing childcare difficulties and toand reaching out to these mothers, the nature ofcomprehensively elucidate interventions for bothsupport for mothers who experience childcare

parties.

difficulties needs to be clarified.

Ⅶ．Limitations

ACKNOWLEDGMENTS

state of mothers

Variations were seen in the backgrounds of

We would like to offer our heartfelt thanks to allmothers, the years of home-visit experience ofthe visiting nurses who spoke about their actual

the visiting nurses, and experiences (testimonials)

experiences of home visits in this study. A partof visiting nurses with first-time mothers, andof this study was presented at the Japan Society

other aspects. Therefore, a bias could also haveof Maternal Health 383-390 July 2015. This work

arisen in the data of this study. Moreover, thewas supported by a research grant of FRANCE

researchers’ ability to collect and analyze data

BED MEDICAL HOME CARE RESERCH

could also have influenced the results, because of

SUBSIDY PUBLIC INTEREST INCORPORATED

the characteristics of the analytical method.

FOUNDATIONS in 2013, Japan.

Ⅷ．CONCLUSION

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